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on the diagnosis of appendicitis, I attempted incident-
ally to treasure chamber slot machine lay down certain rules for guidance, with the
view of simplifying the methods of reasoning in
given cases, based upon the relation of the leading
symptoms to pathological conditions. Since then a
more extended experience has in the main confirmed
the reliability of most of these observations, and mod-
ified or qualified that of others.
Taking the judiciously conservative ground to oper-
1 Paper read before the Practitioners' Society of New York,
November 6, 1896.
ate or not to operate as the occasion demands, we
may appeal treasure chamber online impartially to the common sense of the
general practitioner, who is usually the first to advise
in the premises. He is always prompt in making his
diagnosis, but not equally so in appreciating the ele-
ments in the danger of delay, which a more careful
watching of the case may avert. In private practice
the responsibility of advising any operation is always
attended with difficulty when the reasons for such a
course are not well fixed. In remote districts expert
surgical advice is not always readily obtainable, save
at considerable expense, and the country practitioner,
especially, is oftentimes in doubt as to the expediency
of suggesting surgical consultation in what may prove
to be a simple and uncomplicated case. The latter are
numerous and frequent enough to deserve calm con-
sideration. They demonstrate in the practice of every
one that there is such a thing as safe conservatism,
and that patients recover without operation and re-
main perfectly well for long and indefinite periods.
Thus, while every case should be watched and studied
for dangerous symptoms, there is something else to be
thought of than an immediate operation.
As a proper starting-point for the consideration of
the particular subject of these remarks, it may be said
that what localized pain is to a diagnosis, so is the
increased pulse rate to operation. Of all the symp-
toms indicating danger that of the condition of the
pulse is the most important. This is by no means a
new observation, but one which is either not suffi-
ciently enforced or not properly appreciated. I have
been led to believe, from personal observation in a
goodly number of cases, operative and otherwise, that
this is the main and oftentimes the only guide to oper-
ative interference. Other signs may be wanting, but
this seldom fails. A " snappy" inflammatory pulse,
continuously accelerated or increasing in frequency, is
almost always an indication for operation. This al-
ways shows an actively progressive pathological con-
dition.
The next important consideration is that of the
character, localization, and persistence or increase of
pain. Localized pain at McBurney's point, although
an essential element for diagnosis, is of secondary ac-
count as compared with the pulse in estimating the
indications for operation. While it should always be treasure chamber slots free play
present to a treasure chamber slot games greater or less degree treasure chamber slot in all cases, its pro-
gressive intensity, which means so much, is not always
manifest, even in the worst cases. Usually, however,
the two essential elements of the pain symptom, with
distinct localization and progressive intensity, corres-
spond with the increase of frequency of the pulse. The
sudden increase of pain is an indication of serious
mischief, and u hen present outweighs that of mere tem-
perature elevation in the argument for immediate op-
eration. It is a leading symptom in perforation, in the
so-called fulminating cases, and, save in exceptional
cases, is always attended with symptoms of severe
shock, usually with preliminary chill and generally
with rapidly increased temperature.
The temperature in appendicitis is never very high ;
as a rule, the average is about 102° F. Without the
symptoms previously stated, there may be a reasonable
doubt as to the correctness of a diagnosis. By itself,
MEDICAL RECORD.
[January 9, [897
then, it means very little in our present estimate, but,
associated with the other phenomena named, it makes
assurance doubly sure. In fact, the increase of the
three elements in the order of their importance, pulse
rate first, pain second, and temperature last, constitute
the cardinal indications for operation in every case;
and, contrariwise, a decrease along the same lines, but
more especially in the pain and pulse rate, means judi-
cious waiting and safe conservatism. The actual
number of pulse beats is not of so much account as
their tendency to increase, although the rule of Willy
Meyer, to operate when they reach from 116 to 120,
is generally a trustworthy one, as I have proved in
many instances.
While I desire to emphasize these points as the
really essential ones upon which quite positive opin-
ions may be based, we are not to lose sight of inciden-
tal circumstances which may be considered in the way
of corroborating or of modifying final conclusions.
Aside from the symptoms already mentioned, the gen-
eral gravity of a case has a direct relation to severity
and suddenness of the attack, but more particularly to
the associated condition of prostration of the patient.
He has what is graphically called " a very sick look"
— always an ominous and anxious symptom, and almost
invariably accompanying one or more of the cardinal
signs of danger.
In the foregoing resume we have taken into account
only those symptoms usually noticed in the majority
of cases which from the very nature of the disease re-
quire careful study and accurate interpretation.
Just here it may be stated that there is usually no
necessity for hurry in arriving at conclusions. Ex-
cept in the fulminating cases there is always oppor-
tunity offered for noting the course of the disease.
The initiative symptoms are generally very pronounced
and exaggerated. A snap diagnosis is always unsafe
under the circumstances. After the explosion of the
primary attack there is a comparative retrogressive
lull, and then comes at the end of from twenty-four to
thirty-six hours, or longer, the important time for the
study of what can then be demonstrated as the progres-
sive signs of trouble.
The fulminating cases, however, in which immedi-
ate perforation occurs, admit of no argument as to the
necessity of prompt and radical measures. Nor is
there any danger of misunderstanding the significance
of their symptoms. The sudden agonizing pain, first
localized and then becoming general, the rapid thready
pulse, the pinched face, hurried grunting respiration,
increased temperature, and abdominal distention leave
no doubt in the mind of the most casual observer. In
the majority of these cases the increase of the pulse
rate often anticipates that of pain and temperature.
While every one knows that all cases of appendi-
citis require the most constant and careful watching
until actual recovery takes place, that we are never out
of danger until all symptoms of the disease have dis-
appeared, it is also true that there is no necessity ol
becoming alarmed without cause, or becoming acces-
sory to the patient's death by an overanxiety to oper-
ate. It is with the view of enabling the practitioner
to take a common-sense view of the question that this
effort to formulate certain rules is attempted, in the
hope that by being forewarned he can be safely ready
and lie the better qualified to study indications with
becoming calmness, and not be forced into unwarrant-
able exploratory operations against the dictates of his
better judgment. This may sound like a surgical her-
esy, but we must admit, nevertheless, that we can al-
ways afford to wait for emergencies rather than be 1
eager to anticipate what may never happen.
I cannot help believing that, with a laudable at-